Cycle 1
Health 2025-06-12 · Fire 2025-06-12
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Des Moines, IA
Wesley on Grand
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3520 Grand Avenue, Des Moines, IA
(515) 271-6500
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
76
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Wesleylife
Operator or chain grouping
Approved since
2003-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.70
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.69
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.05
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.74
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
4.17
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,444
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.17% · Performance 21.33% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.62
Baseline 4.64% · Performance 6.45% · Measure score 4.62 · Achievement 4.62 · Improvement 0
Total nurse turnover
1.33
Baseline 62.14% · Performance 58.24% · Measure score 1.33 · Achievement 1.33 · Improvement 0.54
Adjusted total nurse staffing
3.5
Baseline 4.29 hours · Performance 4.07 hours · Measure score 3.5 · Achievement 3.5 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.02% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 229 · Observed rate 6.55% · Lower 95% interval 6.47% |
| Discharge to community | 61.82% |
50.57%
11.2 pts better
|
Better than the National Rate · Eligible stays 213 · Observed rate 58.69% · Lower 95% interval 55.16% |
| Medicare spending per beneficiary | 0.67 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 194 · Denominator 194 |
| Falls with major injury | 1.55% |
0.77%
0.8 pts worse
|
Numerator 3 · Denominator 194 |
| Discharge self-care score | 46.15% |
53.69%
7.5 pts worse
|
Numerator 72 · Denominator 156 |
| Discharge mobility score | 46.79% |
50.94%
4.1 pts worse
|
Numerator 73 · Denominator 156 |
| Pressure ulcers or injuries, new or worsened | 3.09% |
2.29%
0.8 pts worse
|
Numerator 6 · Denominator 194 · Adjusted rate 3.69% |
| Healthcare-associated infections requiring hospitalization | 6.45% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 144 · Observed rate 4.86% · Lower 95% interval 3.64% |
| Staff COVID-19 vaccination coverage | 2.78% |
8.2%
5.4 pts worse
|
Numerator 6 · Denominator 216 |
| Staff flu vaccination coverage | 21.09% |
42%
20.9 pts worse
|
Numerator 27 · Denominator 128 |
| Discharge function score | 51.28% |
56.45%
5.2 pts worse
|
Numerator 80 · Denominator 156 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 40 · Denominator 40 |
| Transfer of health information to patient | 99.15% |
96.28%
2.9 pts better
|
Numerator 117 · Denominator 118 |
| Resident COVID-19 vaccinations up to date | 18.1% |
25.2%
7.1 pts worse
|
Numerator 21 · Denominator 116 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
2.1
1.9 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
94.0%
4 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 98.0% · Q3 97.9% · Q4 98.1% · 4Q avg 98.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
95.2%
1.4 pts better
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.7%
0.7 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 2.1% · Q4 5.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
4.0%
3 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 8.2% |
4.9%
3.3 pts worse
|
5.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 12.1% · Q3 10.0% · Q4 2.8% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.1% |
20.6%
1.5 pts better
|
19.6%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 11.8% · Q3 23.3% · Q4 22.2% · 4Q avg 19.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.4% |
19.8%
1.6 pts worse
|
16.7%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 21.4% · Q3 25.0% · Q4 20.0% · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.8% |
18.5%
3.3 pts worse
|
16.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.0% |
18.3%
3.3 pts better
|
14.9%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 19.4% · Q3 14.8% · Q4 19.4% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.5% |
1.7%
1.8 pts worse
|
1.0%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.7% · Q3 2.5% · Q4 5.1% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
2.5%
0.5 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 2.1% · Q4 1.9% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.1% |
26.0%
11.1 pts worse
|
19.8%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.1% · Q2 41.0% · Q3 42.4% · Q4 30.5% · 4Q avg 37.1% |
| Percentage of long-stay residents with pressure ulcers | 8.8% |
4.3%
4.5 pts worse
|
5.1%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 8.5% · Q3 10.5% · Q4 7.4% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
84.3%
12.5 pts better
|
81.7%
15.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 95.3% · Q3 97.3% · Q4 98.5% · 4Q avg 96.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
13.1%
0.6 pts better
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 11.9% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.9%
0.6 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.0% · Q3 1.7% · Q4 0.8% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.4% |
73.3%
15.1 pts better
|
79.7%
8.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
21.3%
3.7 pts worse
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 24.4% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-11 · Fire 2024-07-11
0 health deficiencies
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-04-20 · Fire 2023-04-20
3 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-06-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-19
F · Potential for more than minimal harm
2024-07-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-01
F · Potential for more than minimal harm
2024-07-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-07-11
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-07-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-07-29
E · Potential for more than minimal harm
2024-07-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-29
E · Potential for more than minimal harm
2024-07-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-01
F · Potential for more than minimal harm
2023-04-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-04
F · Potential for more than minimal harm
2023-04-20
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-05-23
E · Potential for more than minimal harm
2023-04-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-04
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-27
E · Potential for more than minimal harm
2023-04-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-20
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2023-05-19
Penalties and ownership
What sits behind the stars
Ownership
Wesley Retirement Services Inc
5% Or Greater Direct Ownership Interest · Organization
Albertson, Kermit
Corporate Director · Individual
Buskohl, Damon
Operational/Managerial Control · Individual
Gilroy, Abbey
Corporate Director · Individual
Hoeksema, Nicole
Corporate Director · Individual
Kretzinger, Robert
Corporate Officer · Individual
Kretzinger, Robert
W-2 Managing Employee · Individual
Lagree, Roger
Corporate Director · Individual
Rasmussen, Chad
Corporate Director · Individual
Ruch, Robert
Corporate Director · Individual
Simpson, Janet
Operational/Managerial Control · Individual
Stout, David
Corporate Director · Individual
Taylor, Christina
Corporate Director · Individual
Watson, Susan
Corporate Director · Individual
Wesley Retirement Services Inc
Operational/Managerial Control · Organization
Wesleylife
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Scottish Rite Park Inc
Des Moines, IA
5-star overall rating with 4-star inspections with $33,348 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Iowa Jewish Senior Life Center
Des Moines, IA
4-star overall rating with 4-star inspections with $56,807 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Ramsey Village
Des Moines, IA
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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